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A 65-year-old man is admitted to the neurologic intensive care unit (NeuroICU) for altered mental status. He was found “down” by his family at 10:00 am on the morning of admission and was last known to be normal at 11:00 pm the night before. In the field, emergency medical services (EMS) documented his Glasgow Coma Scale score as E2V3M3, blood pressure (BP), 220/110 mm Hg; heart rate, 60 with an A-V paced rhythm; respiration rate (RR), 10, saturating 98% on 100% a nonrebreather mask; bilateral sluggishly reactive pupils, 4→2; doll’s eye test, minimal bilaterally; and extensor posturing bilateral upper and lower extremities to deep painful stimuli. No external signs of trauma. Patient was intubated in the field, and a tertiary stroke center in the vicinity was notified with activation of a stroke code. On arrival to the emergency department (ED), patient was received by the ED and stroke teams.

The past medical history was significant for CAD s/p CABG in 2010, DM-II, systolic HF due to ischemic cardiomyopathy (EF 25%) s/p drug eluting stent to LAD 3 months ago, AVR complicated by complete heart block s/p BiV ICD/PPM in 2011. His medications include ASA 81 mg, Plavix 75 mg, atorvastatin 40 mg, lisinopril 40 mg, metoprolol XL 50 mg q12h, Lantus 40 units SQ qhs.

On arrival his BP is 160/90 mm Hg, and he is sedated on a propofol drip. His examination is similar to EMS initial exam. The stroke team is concerned for a top of the basilar clot vs a massive intracranial hemorrhage (ICH). He is taken for a stat head CT, which shows a 32 cc left putaminal hemorrhage with intraventricular hemorrhage (IVH) in bilateral lateral ventricles and casting of fourth ventricle with acute obstructive hydrocephalus. He is given a mannitol bolus of 100 g stat, hyperventilated; the head of bed is maintained at 30°. The ED team calls for a stat neurosurgery consult for extraventricular drain (EVD) placement and possible clot evacuation. SBP is maintained between 100 and 140 mm Hg with a nicardipine drip, and 2 doses of 23.4% saline are given. The family is updated about the massive ICH and hydrocephalus. They are informed about the potential risk of in-stent thrombosis with anti-platelet reversal, and the patient is given one pack SDU platelets and DDAVP, 0.3 μg/kg ×1. The neurosurgery team places an EVD using a right frontal approach. The initial ICP is 30 mm Hg. Clot evacuation is not pursued given the deep location of the hematoma, and the patient is transferred to the NeuroICU.

With risk of in-stent thrombosis, the plan is to restart aspirin about day 7 but hold off on Plavix while the EVD is in place. Post-bleed day 4, the patient develops a Tmax of 39.8, and he is pan-cultured and started on broad spectrum antibiotics-vancomycin and cefepime; CSF is sent from the EVD. His examination worsened: GCS, E1VtM1. Cerebrospinal fluid Gram stain shows few GPCs in clusters, indicating ...

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